Hemodialysis

Assessing the understandability and actionability of online resources for patients undergoing hemodialysis

INTRODUCTION

This study quantitatively evaluated the understandability and actionability of webpages for patients undergoing hemodialysis (HD).

METHODS

In June 2022, we searched on Google and Yahoo Japan using the top five keywords associated with end-stage kidney disease and HD to identify relevant materials. Subsequently, we used the Japanese version of the Patient Education Materials Assessment Tool to assess the understandability and actionability of these materials, rating them on a scale from 0% to 100%. The threshold was set at 70%.

RESULTS

Among the included 194 materials, the overall understandability was 66.7%, and the actionability was 33.3%. Only 38.7% and 16.5% of the materials were deemed understandable and actionable, respectively. Challenges included the need for plain language and concise summaries to improve understandability, along with the use of effective visual aids for actionability.

CONCLUSION

This study suggests that existing webpages on HD are not presented in a manner that patients can utilize.

Global, regional, and national burden of chronic kidney disease and its underlying etiologies from 1990 to 2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

We aimed to investigate global, regional, and national burden of chronic kidney disease (CKD) and its underlying etiologies from 1990 to 2021.

METHODS

We summarized the results of the Global Burden of Disease (GBD) 2021 to derive the disease burden of CKD by considering four distinct types of epidemiological data, namely incidence, prevalence, mortality, and disability-adjusted life years (DALYs). The Joinpoint regression analysis, which is skilled in calculating annual percentage change (APC) and average annual percentage change (AAPC), was used to estimate global trends for CKD from 1990 to 2021.

RESULTS

The age-standardized mortality rate (ASMR) and age-standardized DALYs rate of CKD were more prominent in regions with Low and Low-middle socio-demographic index (SDI) quintiles. From 1990 to 2021, the countries with the largest increases in ASMR were Ukraine. Globally, the most common cause of death for CKD was type 2 diabetes mellitus (T2DM), while the most common cause of prevalence, incidence, and DALYs was the other and unspecified causes. The main causes of death and DALYs from CKD varied in different parts of the world. The disease burden of CKD increased with age. In most age groups, the global prevalence and incidence of CKD were higher in females than males. At all ages, the global mortality rate and DALYs rate of CKD were higher in males compared to females. Joint point regression analysis found that from 1990 to 2021 the global age-standardized prevalence rate (ASPR) revealed a downward trend, while age-standardized incidence rate (ASIR), ASMR, and age-standardized DALYs rate showed an upward trend, with the most notable increase in ASMR during the 1997-2000 period and in age-standardized DALYs rate during the 1996-2003 period.

CONCLUSIONS

The study unveiled the uneven global distribution of the burden of CKD and its attributable causes. From 1990 to 2021, an increase in the burden of incidence, mortality, and DALYs due to CKD was observed. Population growth and aging will contribute to a further increase in the burden of CKD. Healthcare providers should develop health policies, and optimize the allocation of medical resources, based on age, sex, region, and disease type.

Effect of selenium supplementation on hemodialysis patients: a meta-analysis

PURPOSE

Hemodialysis (HD) patients commonly experience enhanced oxidative stress and inflammation, potentially increasing the risk of malnutrition. Selenium levels are typically lower in HD individuals. Selenium deficiency has been identified as a risk factor for oxidative stress and inflammatory responses. Therefore, we intended to perform a meta-analysis to assess the impact of selenium supplementation on HD patients.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched for randomized controlled trials (RCTs) on the effect of selenium supplementation on HD patients until September 31, 2024. The data analysis was conducted using Stata15.0 software.

RESULTS

Seven RCTs, with 2080 participants, were finally included, with 1029 in the selenium group and 1051 in the control group. The meta-analysis unraveled no statistically significant impact of selenium supplementation on body mass index (SMD = 0.15, 95% CI (- 0.20, 0.49), triglyceride [(SMD = - 0.02, 95% CI (- 0.44, 0.41)], total cholesterol [(SMD = - 0.18, 95%CI (- 0.41, 0.05)], low-density lipoprotein [(SMD = - 0.37, 95% CI (- 1.04, 0.31)], high-density lipoprotein cholesterol [(SMD = 0.15, 95% CI (- 0.54, 0.84)], C-reactive protein [(SMD = - 0.10, 95% CI (- 0.46, 0.27)], ferritin [(SMD = - 0.02, 95% CI (- 0.29, 0.26)], Hx-C reactive protein [(SMD = 0.00, 95% CI (- 1.02, 1.03)], and hemoglobin [(SMD = 0.01, 95% CI (- 0.57,0.59)]. Only selenium levels were significantly increased after selenium supplementation [SMD = 2.83, 95% CI (2.43, 3.24)].

CONCLUSION

Selenium supplementation can increase selenium levels in HD patients, without notable impacts on weight, triglycerides, and total cholesterol.

Characteristics of tongue coating microbiota in diabetic and non-diabetic kidney patients receiving hemodialysis

BACKGROUND

Tongue-coating microbiota, especially known as the tongue microbiome, holds significant value as both a prospective clinical diagnostic biomarker and therapeutic target, which plays a crucial role in the oral microecological health. However, there is limited understanding of the composition and function of tongue coating microbiota in chronic kidney disease patients undergoing hemodialysis.

METHODS

Thirty-one non-diabetic hemodialysis patients (nonDM_HD), 29 diabetic hemodialysis patients (DM_HD) and 33 healthy controls (HC) were enrolled. Swabs from tongue coating were collected. The 16S rDNA (V3-V4 region) was sequenced to scrutinize the tongue-coating bacterial microbiome difference.

RESULTS

Both nonDM_HD and DM_HD showed distinct bacterial communities of oral microbiota compared to HC. The abundance of Streptococcus, Lactobacillus, Ruminococcaceae G1, Ligilactobacillus and Abiotrophia showed a significant increase (p < 0.05) in DM_HD and nonDM_HD compared to HC, while Haemophilus, Lachnoanaerobaculum, Peptostreptococcaceae G1, Peptostreptococcus showed a significant decrease (p < 0.05) respectively. Veillonella, Lactobacillus, Limosilactobacillus etc. may serve as potential biomarkers for DM_HD. While Streptococcus, Ruminococcaceae G1, Actinobacillus, Abiotrophia can be considered alternative biomarkers for nonDM_HD. Moreover, the enriched Haemophilus, Actinomyces, Lachnoanaerobaculum were prominent features of the tongue coating microbiota in HC, which could be used as the potential therapeutic targets of chronic kidney disease. Network analysis revealed a less complex interaction relationship among the tongue coating bacterial microbiota of nonDM_HD and DM_HD. Furthermore, correlations were identified between the microbiome composition and clinical parameters of the individuals.

CONCLUSION

In conclusion, deciphering the tongue coating microbiota of kidney patients undergoing hemodialysis will helpful in assessing the role of oral microbiota in pathobiology and development of kidney disease, which is expected to become a potential biomarkers and adjuvant therapeutic target.

A soft thermal sensor for the continuous assessment of flow in vascular access

Hemodialysis for chronic kidney disease (CKD) relies on vascular access (VA) devices, such as arteriovenous fistulas (AVF), grafts (AVG), or catheters, to maintain blood flow. Nonetheless, unpredictable progressive vascular stenosis due to neointimal formation or complete occlusion from acute thrombosis remains the primary cause of mature VA failure. Despite emergent surgical intervention efforts, the lack of a reliable early detection tool significantly reduces patient outcomes and survival rates. This study introduces a soft, wearable device that continuously monitors blood flow for early detection of VA failure. Using thermal anemometry, integrated sensors noninvasively measure flow changes in large vessels. Bench testing with AVF and AVG models shows agreement with finite element analysis (FEA) simulations, while human and preclinical swine trials demonstrate the device's sensitivity. Wireless adaptation could enable at-home monitoring, improving detection of VA-related complications and survival in CKD patients.

Understanding Vascular Calcification in Chronic Kidney Disease: Pathogenesis and Therapeutic Implications

Vascular calcification (VC) is a biological phenomenon characterized by an accumulation of calcium and phosphate deposits within the walls of blood vessels causing the loss of elasticity of the arterial walls. VC plays a crucial role in the incidence and progression of chronic kidney disease (CKD), leading to a significant increase in cardiovascular mortality in these patients. Different conditions such as age, sex, dyslipidemia, diabetes, and hypertension are the main risk factors in patients affected by chronic kidney disease. However, VC may occur earlier and faster in these patients if it is associated with new or non-traditional risk factors such as oxidative stress, anemia, and inflammation. In chronic kidney disease, several pathophysiological processes contribute to vascular calcifications, including osteochondrogenic differentiation of vascular cells, hyperphosphatemia and hypercalcemia, and the loss of specific vascular calcification inhibitors including pyrophosphate, fetuin-A, osteoprotegerin, and matrix GLA protein. In this review we discuss the main traditional and non-traditional risk factors that can promote VC in patients with kidney disease. In addition, we provide an overview of the main pathogenetic mechanisms responsible for VC that may be crucial to identify new prevention strategies and possible new therapeutic approaches to reduce cardiovascular risk in patients with kidney disease.

Epidemiological analysis of chronic kidney disease from 1990 to 2019 and predictions to 2030 by Bayesian age-period-cohort analysis

BACKGROUND

Chronic Kidney Disease (CKD) has emerged as a significant global health issue. This study aimed to reveal and predict the epidemiological characteristics of CKD.

METHODS

Data from the Global Burden of Disease Study spanning the years 1990 to 2019 were employed to analyze the incidence, prevalence, death, and disability-adjusted life year (DALY) of CKD. Joinpoint analysis assessed epidemiological trends of CKD from 1990 to 2019. An age-period-cohort model evaluated risk variations. Risk factor analysis uncovered their influences on DALYs and deaths of CKD. Decomposition analysis explored the drivers to CKD. Frontier analysis evaluated the correlations between CKD burden and the sociodemographic index (SDI). A Bayesian Age-Period-Cohort model was employed to predict future incidence and death of CKD.

RESULTS

In 2019, there were 18,986,903 incident cases, 697,294,307 prevalent cases, 1,427,232 deaths, and 41,538,592 DALYs of CKD globally. Joinpoint analysis showed increasing age-standardized rates of CKD incidence, prevalence, mortality, and DALY from 1990 to 2019. High systolic blood pressure significantly contributed to CKD-related deaths and DALYs, particularly in the high SDI region. Decomposition analysis identified population growth as the primary driver of CKD incident cases and DALYs globally. Countries like Nicaragua showed the highest effective differences, indicating room for improvement in CKD management. By 2030, while incident cases of CKD were predicted to rise, the global deaths might decrease.

CONCLUSIONS

The study revealed a concerning upward trend in the global burden of CKD, emphasizing the need for targeted management strategies across different causes, regions, age groups, and genders.

Development and validation of a prediction model for all-cause mortality in maintenance dialysis patients: a multicenter retrospective cohort study

BACKGROUND

The mortality risk varies considerably among individual dialysis patients. This study aimed to develop a user-friendly predictive model for predicting all-cause mortality among dialysis patients.

METHODS

Retrospective data regarding dialysis patients were obtained from two hospitals. Patients in training cohort (N = 1421) were recruited from the Fifth Affiliated Hospital of Sun Yat-sen University, and patients in external validation cohort (N = 429) were recruited from the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine. The follow-up endpoint event was all-cause death. Variables were selected by LASSO-Cox regression, and the model was constructed by Cox regression, which was presented in the form of nomogram and web-based tool. The discrimination and accuracy of the prediction model were assessed using C-indexes and calibration curves, while the clinical value was assessed by decision curve analysis (DCA).

RESULTS

The best predictors of 1-, 3-, and 5-year all-cause mortality contained nine independent factors, including age, body mass index (BMI), diabetes mellitus (DM), cardiovascular disease (CVD), cancer, urine volume, hemoglobin (HGB), albumin (ALB), and pleural effusion (PE). The 1-, 3-, and 5-year C-indexes in the training set (0.840, 0.866, and 0.846, respectively) and validation set (0.746, 0.783, and 0.741, respectively) were consistent with comparable performance. According to the calibration curve, the nomogram predicted survival accurately matched the actual survival rate. The DCA showed the nomogram got more clinical net benefit in both the training and validation sets.

CONCLUSIONS

The effective and convenient nomogram may help clinicians quantify the risk of mortality in maintenance dialysis patients.

Participation in eHealth Communication Interventions Among Patients Undergoing Hemodialysis: Scoping Review

BACKGROUND

eHealth communication interventions have been shown to offer individuals with chronic kidney disease the opportunity to embrace dialysis therapies with greater confidence, the potential to obtain better clinical outcomes, and an increased quality of life. eHealth is an emerging field that offers diverse, flexible designs and delivery options. However, existing evidence on eHealth communication among patients undergoing hemodialysis is sparse and scattered and lacks systematization.

OBJECTIVE

This scoping review aims to identify and map the current evidence on patient participation in eHealth communication interventions. We aimed to map the associations between interventions and electronic health records, the participative role of individuals living with chronic kidney disease and undergoing hemodialysis, and the barriers to and facilitators of patient involvement in eHealth communication with health care professionals.

METHODS

This study used the Joanna Briggs Institute methodology for conducting a scoping review. Studies eligible for inclusion were those that included adult patients (aged >18 y) undergoing all types of hemodialysis, including prescheduled in-center hemodialysis and conventional home-based hemodialysis. Systematic searches were completed in Ovid MEDLINE, Ovid Embase, EBSCOhost CINAHL with Full Text, Scopus, and ProQuest Dissertations and Theses. Extracted data from the included studies were presented in figures and tables along with descriptions that responded to the research questions. This review was reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines.

RESULTS

In total, 9 peer-reviewed studies were included. The main result was a low participative patient role and a vaguely described link to electronic health records. The key participative facilitators were availability of and access to the intervention; security, trust, and confidence; patient knowledge of their health situation and use of self-care; and patient preparedness for an uncertain future health situation and the ability to relate to family and friends about it. The key participative barriers were lack of availability of and access to information, mistrust and lack of safety, lack of knowledge of health situation and self-care, and relational issues. All barriers and facilitators were related to health literacy.

CONCLUSIONS

This scoping review summarizes 4 specific and 3 nonspecific eHealth communication interventions developed and evaluated in various studies involving patients receiving hemodialysis. A knowledge gap exists between low levels of patient participation in eHealth communication and patients' limited access to electronic health records. eHealth communication interventions should implement patient participation and focus on the fact that different modalities of eHealth communication can complement face-to-face communication.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/38615.

Prevalence and severity of sarcopenia in patients on maintenance hemodialysis: a cross-sectional study

BACKGROUND

Sarcopenia, the progressive loss of muscle mass and strength, is common among patients with chronic kidney disease, especially those on maintenance hemodialysis. This condition often arises from factors like reduced physical activity and metabolic changes associated with chronic kidney disease. This study aims to assess the prevalence and severity of sarcopenia in patients on maintenance hemodialysis (MHD), focusing on probable sarcopenia and its correlations with physical activity, body mass index, and inorganic phosphorus levels.

METHODS

This cross-sectional study involved 220 patients on MHD who visited to West China Hospital of Sichuan University between February and April 2023. The demographic data, body measurements, and laboratory results were retrospectively collected. Sarcopenia was assessed using the 2019 criteria from the Asian Working Group and the European Working Group on Sarcopenia in Older People, and physical activity was measured via the International Physical Activity Questionnaire.

RESULTS

Of the study participants, 141 (64.1%) were diagnosed with probable [110 (50.0%) or confirmed sarcopenia [31 (14.1%)], including 22 (10%) with severe sarcopenia. Multivariable logistic regression analysis revealed that physical activity (International Physical Activity Questionnaire score, OR = 0.998, 95% CI: 0.998-0.999, P < 0.001), body mass index (OR = 0.868, 95% CI: 0.788-0.957, P = 0.004), and inorganic phosphorus levels (OR = 0.513, 95% CI: 0.270-0.975, P = 0.042) independently influenced the likelihood of sarcopenia. Within the sarcopenic group, physical activity and BMI significantly correlated with the condition's severity.

CONCLUSION

The prevalence of probable or confirmed sarcopenia in patients on MHD is significant. Factors such as physical activity, body mass index, and inorganic phosphorus levels are independently associated the presence and severity of sarcopenia in this population.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100051111), registered on 2021-09-13.

Comparison of inferior vena cava puncture under continuous cardiac perfusion with cardiac puncture in blood acquisition of the laboratory mouse

Obtaining sufficient blood volume from mice significantly facilitates experimental research. This study explored the inferior vena cava puncture under continuous cardiac perfusion (IVCP-UCCP) technique and evaluated its efficiency in comparison with conventional cardiac puncture (CP). In an initial dose-finding study, 50 mice were randomly assigned to one of 10 groups with escalating perfusion volume from 0.5 to 4.5 ml in 0.5-ml increments. The minimum perfusion volume was determined to be 2 ml in collecting whole circulating blood. In the next comparison using the conventional method, 40 mice were randomly assigned to one of two groups denoting different blood collection methods: Group 1: CP, Group 2: IVCP-UCCP. The results showed 1) that the cells and undiluted blood volume collected via IVCP-UCCP was over twofold higher than that by CP (p < 0.001), confirmed by the cell counts and hematoxylin-eosin staining of different tissues slides (p < 0.001); 2) the new technique did not alter the cellular composition or viability, which was verified by routine blood tests and flow cytometry (p > 0.05); 3) the blood collected via the novel technique was diluted 2.1 times: the hemato-biochemical indicator results multiplied by 2.1 were identical with the test results of blood from CP (p > 0.05). Together, the refined blood collection method of IVCP-UCCP completely extracted the limited blood resources in mice, significantly enhanced the utilization of each mouse, and thus offered scientific and ethical benefits. This technique may be also applicable for other small animal models.

The weighing process in patients on hemodialysis: an opportunity to improve volume management

Background

Hemodialysis relies on accurate body mass (BM) assessment to determine ultrafiltration volumes, but we have not identified published practice patterns disclosing how to handle clothing mass. Here we investigated the potential impact of clothing mass on predialysis BM determination, hypothesizing that a standardized template for clothing mass estimation enhances accuracy, compared with conventional practice.

Methods

Measurements included dressed and undressed BM predialysis. A pre-established template for average clothing mass was used to approximate undressed BM from clothed measurements. Differences from undressed BM were compared using Bland-Altman plots and tested for statistical significance using Wilcoxon signed rank tests.

Results

After excluding erroneous results, data from 48 patients were analyzed. Thirty-six patients (75%) did not habitually estimate clothing mass, but used their dressed BM as the predialysis BM, while the other 12 patients (25%) reported deducting a self-estimated clothing mass from their clothed predialysis BM. The differences from undressed BM were 0.819 ± 0.462 kg and 0.342 ± 0.321 kg in these two groups, respectively, indicating that patients underestimated clothing mass. Using the template to deduct clothing mass from clothed predialysis BM, these differences could be reduced to 0.197 ± 0.220 kg and 0.133 ± 0.135 kg, respectively. The average differences using the patient-reported BM and the template-based BM made up 39.4% and 8.6% of the average subsequent ultrafiltration volume, respectively, suggesting that potential overestimation of the actual ultrafiltration volume could be reduced.

Conclusion

A standardized template for clothing mass may be useful to derive representative predialysis BM, leading to more precise ultrafiltration calculation. Exact BM determination might improve volume management in hemodialysis.

Hypereosinophilia-associated acute intradialytic hypotension: a report of three cases and literature review

Occasionally, patients undergoing dialysis develop acute severe hypotension that requires interruption of dialysis within minutes of initiating every dialysis session. Although the underlying causes of recurrent intradialytic hypotension are evaluated extensively, including dialysis-associated allergic reactions or other possible causes, the definitive cause is sometimes missed. Dialysis is a life-sustaining procedure; therefore, prompt identification and management of the underlying cause of dialysis intolerance are crucial. Herein, we report three cases of patients undergoing dialysis who presented with hypereosinophilia-associated acute intradialytic hypotension. All three patients developed acute severe hypotension within minutes after the start of every dialysis session. The prescriptions for dialysis were changed, but episodes of intradialytic hypotension persisted. Pretreatment with methylprednisolone given intravenously before the dialysis session was also ineffective. All patients had hypereosinophilia (> 1500/μL) of different etiology. Eosinophil-lowering therapy with 0.5 mg/kg of prednisolone given orally daily was initiated, and all of them could restart dialysis without any hypotensive episodes within a few days. Our case report and literature review indicated that hypereosinophilia, regardless of its etiology, could result in severe acute hypotension shortly after the start of dialysis session. The oral administration of prednisolone daily was highly effective on hypereosinophilia-associated intradialytic hypotension, while pretreatment with intravenous corticosteroid therapy just before dialysis had no effect. Hypereosinophilia-associated acute intradialytic hypotension is an under-recognized condition; therefore, clinicians need to be aware of this clinical entity and initiate effective treatment strategies. We also provide a brief summary of previously published cases.

Knowledge, attitude, and practice toward nutrition support and management among hemodialysis patients

Nutrition support is an important care component for patients on hemodialysis. Also, patient self-management is important to maintaining proper nutritional intake during hemodialysis. This cross-sectional study investigated the knowledge, attitude, and practice (KAP) towards nutrition support and management among hemodialysis patients treated at the West China Hospital of Sichuan University between January and March 2023. Among 445 (95.91%) valid questionnaires, 58.43% were filled out by male patients. The knowledge, attitude, and practice scores were 11.44 ± 1.80 (possible range: 0-13), 30.29 ± 3.22 (possible range: 8-40), and 31.27 ± 5.67 (possible range: 8-40), respectively. Age > 60 years (OR = 0.487, 95%CI: 0.260-0.913, P = 0.025) and junior college or undergraduate or above (OR = 2.606, 95%CI: 1.621-4.189, P < 0.001) were independently associated with adequate knowledge. The knowledge (OR = 1.151, 95%CI: 1.024-1.294, P = 0.018) and female gender (OR = 0.632, 95%CI: 0.419-0.953, P = 0.029) were independently associated with positive attitude. The knowledge (OR = 1.404, 95%CI: 1.221-1.614, P < 0.001), attitude (OR = 1.146, 95%CI: 1.069-1.227, P < 0.001), age 51-60 years (OR = 1.879, 95%CI: 1.093-3.229, P = 0.022), and BMI of 24.0-27.9 kg/m2 (OR = 0.434, 95%CI: 0.269-0.700, P = 0.001) were independently associated with proactive practice. Hemodialysis patients showed adequate knowledge, positive attitudes, and proactive practice; however, there were also several gaps in knowledge and misconceptions regarding proper nutritional self-management. Accordingly, addressing these gaps and misconceptions through carefully designed and effectively implemented education is crucial for providing comprehensive guidance on optimal nutrition and self-management strategies.

The use of Hub Devices to reduce catheter-related infections in dialysis patients: A narrative review

INTRODUCTION

Catheter-related bloodstream infections are among the most critical issues associated with central venous catheters used for dialysis treatment. To reduce the incidence of this life-threatening complication, various strategies have been developed. Among these, Hub Devices have been introduced in clinical practice to prevent microbial growth at the hub of the catheter.

METHODS

A review was conducted to assess the effectiveness of Hub Devices in reducing bloodstream infections in central venous catheters for dialysis, compared to solid caps. The review analyzed existing literature from three bibliographic databases (PubMed, Embase, and CINAHL) to provide evidence-based recommendations for clinical practice.

RESULTS

After a thorough review of the available data, it was found that out of the 873 records screened, only six trials met the inclusion criteria. Albeit the number of patients observed in these trials was more than 25,000, due to the differences in the mechanism of action of different Hub Devices and the lack of a standardized criterion to identify and measure the outcomes, it is difficult to draw a firm conclusion. It is worth noting, however, that in five out of six trials examined, the Hub Devices exhibited a protective effect when compared to solid caps.

CONCLUSIONS

The use of Hub Devices appears to be associated with a reduction in catheter-related bloodstream infections in the central venous catheter dialysis population. However, the Hub Devices show interesting results that should be investigated with further well-designed prospective studies.

Hemodialysis Vascular Access: A Historical Perspective on Access Promotion, Barriers, and Lessons for the Future

This review describes the history of vascular access for hemodialysis (HD) over the past 8 decades. Reliable, repeatable vascular access for outpatient HD began in the 1960s with the Quinton-Scribner shunt. This was followed by the autologous Brecia-Cimino radial-cephalic arteriovenous fistula (AVF), which dominated HD vascular access for the next 20 years. Delayed referral and the requirement of 1.5-3 months for AVF maturation led to the development of and increasing dependence on synthetic arteriovenous grafts (AVGs) and tunneled central venous catheters, both of which have higher thrombosis and infection risks than AVFs. The use of AVGs and tunneled central venous catheters increased progressively to the point that, in 1997, the first evidence-based clinical practice guidelines for HD vascular access recommended that they only be used if a functioning AVF could not be established. Efforts to promote AVF use in the United States during the past 2 decades doubled their prevalence; however, recent practice guidelines acknowledge that not all patients receiving HD are ideally suited for an AVF. Nonetheless, improved referral for AVF placement before dialysis initiation and improved conversion of failing AVGs to AVFs may increase AVF use among patients in whom they are appropriate.

Precision Dialysis: Leveraging Big Data and Artificial Intelligence

The long-term mortality of patients with kidney failure remains unacceptably high. There are a multitude of reasons for the unfavorable status quo of dialysis care, such as the inadequate and suboptimal pattern of uremic toxin removal resulting in a metabolic and hemodynamic "roller coaster" induced by thrice-weekly in-center hemodialysis. Innovation in dialysis delivery systems is needed to build an adaptive and self-improving process to change the status quo of dialysis care with the aim of transforming it from being reactive to being proactive. The introduction of more physiologic and smart dialysis systems using artificial intelligence (AI) incorporating real-time data into the process of dialysis delivery is a realistic target. This would enable machine learning from both individual and collective patient treatment data. This has the potential to shift the paradigm from the practice of population-driven, evidence-based data to precision medicine. In this review, we describe the different components of an AI system, discuss the studied applications of AI in the field of dialysis, and outline parameters that can be used for future smart, adaptive dialysis delivery systems. The desired output is precision dialysis; a self-improving process that has the ability to prognosticate and develop instant and individualized predictive models.

The application of blood flow sound contrastive learning to predict arteriovenous graft stenosis of patients with hemodialysis

End-stage kidney disease (ESKD) presents a significant public health challenge, with hemodialysis (HD) remaining one of the most prevalent kidney replacement therapies. Ensuring the longevity and functionality of arteriovenous accesses is challenging for HD patients. Blood flow sound, which contains valuable information, has often been neglected in the past. However, machine learning offers a new approach, leveraging data non-invasively and learning autonomously to match the experience of healthcare professionas. This study aimed to devise a model for detecting arteriovenous grafts (AVGs) stenosis. A smartphone stethoscope was used to record the sound of AVG blood flow at the arterial and venous sides, with each recording lasting one minute. The sound recordings were transformed into mel spectrograms, and a 14-layer convolutional neural network (CNN) was employed to detect stenosis. The CNN comprised six convolution blocks with 3x3 kernel mapping, batch normalization, and rectified linear unit activation function. We applied contrastive learning to train the pre-training audio neural networks model with unlabeled data through self-supervised learning, followed by fine-tuning. In total, 27,406 dialysis session blood flow sounds were documented, including 180 stenosis blood flow sounds. Our proposed framework demonstrated a significant improvement (p<0.05) over training from scratch and a popular pre-trained audio neural networks (PANNs) model, achieving an accuracy of 0.9279, precision of 0.8462, and recall of 0.8077, compared to previous values of 0.8649, 0.7391, and 0.6538. This study illustrates how contrastive learning with unlabeled blood flow sound data can enhance convolutional neural networks for detecting AVG stenosis in HD patients.

AI-based segmentation of renal enhanced CT images for quantitative evaluate of chronic kidney disease

To quantitatively evaluate chronic kidney disease (CKD), a deep convolutional neural network-based segmentation model was applied to renal enhanced computed tomography (CT) images. A retrospective analysis was conducted on a cohort of 100 individuals diagnosed with CKD and 90 individuals with healthy kidneys, who underwent contrast-enhanced CT scans of the kidneys or abdomen. Demographic and clinical data were collected from all participants. The study consisted of two distinct stages: firstly, the development and validation of a three-dimensional (3D) nnU-Net model for segmenting the arterial phase of renal enhanced CT scans; secondly, the utilization of the 3D nnU-Net model for quantitative evaluation of CKD. The 3D nnU-Net model achieved a mean Dice Similarity Coefficient (DSC) of 93.53% for renal parenchyma and 81.48% for renal cortex. Statistically significant differences were observed among different stages of renal function for renal parenchyma volume (VRP), renal cortex volume (VRC), renal medulla volume (VRM), the CT values of renal parenchyma (HuRP), the CT values of renal cortex (HuRC), and the CT values of renal medulla (HuRM) (F = 93.476, 144.918, 9.637, 170.533, 216.616, and 94.283; p < 0.001). Pearson correlation analysis revealed significant positive associations between glomerular filtration rate (eGFR) and VRP, VRC, VRM, HuRP, HuRC, and HuRM (r = 0.749, 0.818, 0.321, 0.819, 0.820, and 0.747, respectively, all p < 0.001). Similarly, a negative correlation was observed between serum creatinine (Scr) levels and VRP, VRC, VRM, HuRP, HuRC, and HuRM (r = - 0.759, - 0.777, - 0.420, - 0.762, - 0.771, and - 0.726, respectively, all p < 0.001). For predicting CKD in males, VRP had an area under the curve (AUC) of 0.726, p < 0.001; VRC, AUC 0.765, p < 0.001; VRM, AUC 0.578, p = 0.018; HuRP, AUC 0.912, p < 0.001; HuRC, AUC 0.952, p < 0.001; and HuRM, AUC 0.772, p < 0.001 in males. In females, VRP had an AUC of 0.813, p < 0.001; VRC, AUC 0.851, p < 0.001; VRM, AUC 0.623, p = 0.060; HuRP, AUC 0.904, p < 0.001; HuRC, AUC 0.934, p < 0.001; and HuRM, AUC 0.840, p < 0.001. The optimal cutoff values for predicting CKD in HuRP are 99.9 Hu for males and 98.4 Hu for females, while in HuRC are 120.1 Hu for males and 111.8 Hu for females. The kidney was effectively segmented by our AI-based 3D nnU-Net model for enhanced renal CT images. In terms of mild kidney injury, the CT values exhibited higher sensitivity compared to kidney volume. The correlation analysis revealed a stronger association between VRC, HuRP, and HuRC with renal function, while the association between VRP and HuRM was weaker, and the association between VRM was the weakest. Particularly, HuRP and HuRC demonstrated significant potential in predicting renal function. For diagnosing CKD, it is recommended to set the threshold values as follows: HuRP < 99.9 Hu and HuRC < 120.1 Hu in males, and HuRP < 98.4 Hu and HuRC < 111.8 Hu in females.

Concerns about the application of resistance exercise with blood-flow restriction and thrombosis risk in hemodialysis patients

BACKGROUND

Hemodialysis (HD) per se is a risk factor for thrombosis. Considering the growing body of evidence on blood-flow restriction (BFR) exercise in HD patients, identification of possible risk factors related to the prothrombotic agent D-dimer is required for the safety and feasibility of this training model. The aim of the present study was to identify risk factors associated with higher D-dimer levels and to determine the acute effect of resistance exercise (RE) with BFR on this molecule.

METHODS

Two hundred and six HD patients volunteered for this study (all with a glomerular filtration rate of <15 mL/min/1.73 m2). The RE + BFR session consisted of 50% arterial occlusion pressure during 50 min sessions of HD (intradialytic exercise). RE repetitions included concentric and eccentric lifting phases (each lasting 2 s) and were supervised by a strength and conditioning specialist.

RESULTS

Several variables were associated with elevated levels of D-dimer, including higher blood glucose, citrate use, recent cardiovascular events, recent intercurrents, higher inflammatory status, catheter as vascular access, older patients (>70 years old), and HD vintage. Furthermore, RE + BFR significantly increases D-dimer after 4 h. Patients with borderline baseline D-dimer levels (400-490 ng/mL) displayed increased risk of elevating D-dimer over the normal range (≥500 ng/mL).

CONCLUSION

These results identified factors associated with a heightened prothrombotic state and may assist in the screening process for HD patients who wish to undergo RE + BFR. D-dimer and/or other fibrinolysis factors should be assessed at baseline and throughout the protocol as a precautionary measure to maximize safety during RE + BFR.

Continuous Monitoring of Advanced Hemodynamic Parameters during Hemodialysis Demonstrated Early Variations in Patients Experiencing Intradialytic Hypotension

Intradialytic hypotension (IDH) is a severe complication of hemodialysis (HD) with a significant impact on morbidity and mortality. In this study, we used a wearable device for the continuous monitoring of hemodynamic vitals to detect hemodynamic changes during HD and attempted to identify IDH. End-stage kidney disease patients were continuously monitored 15 min before starting the session and until 15 min after completion of the session, measuring heart rate (HR), noninvasive cuffless systolic and diastolic blood pressure (SBP and DBP), stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR). Data were analyzed retrospectively and included comparing BP measured by the wearable devices (recorded continuously every 5 s) and the cuff-based devices. A total of 98 dialysis sessions were included in the final analysis, and IDH was identified in 22 sessions (22.5%). Both SBP and DBP were highly correlated (r > 0.62, p < 0.001 for all) between the wearable device and the cuff-based measurements. Based on the continuous monitoring, patients with IDH had earlier and more profound reductions in SBP and DBP during the HD treatment. In addition, nearly all of the advanced vitals differed between groups. Further studies should be conducted in order to fully understand the potential of noninvasive advanced continuous monitoring in the prediction and prevention of IDH events.

The relationship between fatigue, pruritus, and thirst distress with quality of life among patients receiving hemodialysis: a mediator model to test concept of treatment adherence

Hemodialysis is a conservative treatment for end-stage renal disease. It has various complications which negatively affect quality of life (QOL). This study aimed to examine the relationship between fatigue, pruritus, and thirst distress (TD) with QOL of patients receiving hemodialysis, while also considering the mediating role of treatment adherence (TA). This cross-sectional study was carried out in 2023 on 411 patients receiving hemodialysis. Participants were consecutively recruited from several dialysis centers in Iran. Data were collected using a demographic information form, the Fatigue Assessment Scale, the Thirst Distress Scale, the Pruritus Severity Scale, the 12-Item Short Form Health Survey, and the modified version of the Greek Simplified Medication Adherence Questionnaire for Hemodialysis Patients. Covariance-based structural equation modeling was used for data analysis. The structural model and hypothesis testing results showed that all hypotheses were supported in this study. QOL had a significant inverse association with fatigue, pruritus, and TD and a significant positive association with TA. TA partially mediated the association of QOL with fatigue, pruritus, and TD, denoting that it helped counteract the negative association of these complications on QOL. This model explained 68.5% of the total variance of QOL. Fatigue, pruritus, and TD have a negative association with QOL among patients receiving hemodialysis, while TA reduces these negative associations. Therefore, TA is greatly important to manage the associations of these complications and improve patient outcomes. Healthcare providers need to assign high priority to TA improvement among these patients to reduce their fatigue, pruritus, and TD and improve their QOL. Further studies are necessary to determine the most effective strategies for improving TA and reducing the burden of complications in this patient population.

Non-invasive assessment of stroke volume and cardiovascular parameters based on peripheral pressure waveform

Cardiovascular diseases are the leading cause of death globally, making the development of non-invasive and simple-to-use tools that bring insights into the state of the cardiovascular system of utmost importance. We investigated the possibility of using peripheral pulse wave recordings to estimate stroke volume (SV) and subject-specific parameters describing the selected properties of the cardiovascular system. Peripheral pressure waveforms were recorded in the radial artery using applanation tonometry (SphygmoCor) in 35 hemodialysis (HD) patients and 14 healthy subjects. The pressure waveforms were then used to estimate subject-specific parameters of a mathematical model of pulse wave propagation coupled with the elastance-based model of the left ventricle. Bioimpedance cardiography measurements (PhysioFlow) were performed to validate the model-estimated SV. Mean absolute percentage error between the simulated and measured pressure waveforms was 4.0% and 2.8% for the HD and control group, respectively. We obtained a moderate correlation between the model-estimated and bioimpedance-based SV (r = 0.57, p<0.05, and r = 0.58, p<0.001, for the control group and HD patients, respectively). We also observed a correlation between the estimated end-systolic elastance of the left ventricle and the peripheral systolic pressure in both HD patients (r = 0.84, p<0.001) and the control group (r = 0.70, p<0.01). These preliminary results suggest that, after additional validation and possibly further refinement to increase accuracy, the proposed methodology could support non-invasive assessment of stroke volume and selected heart function parameters and vascular properties. Importantly, the proposed method could be potentially implemented in the existing devices measuring peripheral pressure waveforms.

The Oral Health Condition of Patients on Hemodialysis at a Tertiary Healthcare Facility in Eastern Nepal

Objectives

This study was done to compare the oral health of chronic kidney disease (CKD) patients on hemodialysis to healthy individuals and to assess the effect of the duration of dialysis on oral health.

Materials and Methods

A comparative cross-sectional study was conducted among purposively selected 54 cases undergoing dialysis and 54 apparently healthy controls. Caries experience and periodontal status were recorded under similar examination conditions and compared between cases and controls. The correlation between oral health and the duration of dialysis was assessed. A p value of <0.05 was considered significant.

Results

The mean age of the participants was 47.09 ± 12.23 years. Median caries experience among cases and controls was two (0-26) and three (0-15), respectively (p=0.013). Periodontitis among the two groups was found to be significantly different with a greater number of cases showing increased severity (p  < 0.001). The severe form of periodontitis was associated with a greater mean duration of dialysis.

Conclusion

Significant differences exist between the periodontal health of patients undergoing dialysis compared to healthy controls. Longitudinal studies are required to check the causal effect of CKD on periodontitis.

Plasma exchange as a tool for removal of bevacizumab: Highlighting application for urgent surgery

Background

Bevacizumab is commonly used to manage cerebral edema associated with brain tumors. However, its long half-life poses challenges for patients requiring urgent surgery due to wound complications. We present a case of utilizing therapeutic plasma exchange (TPE) to remove bevacizumab in a patient with recurrent glioblastoma requiring urgent surgery.

Methods

A 58-year-old male with recurrent glioblastoma, IDH-wildtype, presented with clinical and radiographic concern for ventriculitis requiring urgent wound washout only 4 days after his last bevacizumab infusion. TPE was performed for 3 sessions after surgery using a centrifugation-based cell separator. Replacement fluids included normal serum albumin, normal saline, and fresh frozen plasma. Bevacizumab levels were quantified using an enzyme-linked immunoabsorbent assay before and after each TPE session.

Results

TPE effectively removed bevacizumab, enabling safe surgery without new complications. Plasma bevacizumab levels decreased from 1087.63 to 145.35 ng/mL (13.4% of original) by the end of the last TPE session. This decline is consistent with nearly 3 half-lives, which compares favorably to the expected timeline of natural decline given the 21-day half-life.

Conclusions

We report a complex clinical scenario of a patient requiring urgent wound washout 4 days after last bevacizumab infusion for CNS infection. Surgery was successfully performed without new complications with use of TPE to remove bevacizumab immediately following surgery. This case highlights the feasibility of this approach, which may be utilized effectively in patients requiring surgery after having recently received bevacizumab.

Elevated plasma leptin levels are associated with vascular access dysfunction in patients on maintenance hemodialysis

BACKGROUND

Inflammation has been associated with vascular access (VA) dysfunction. The adipocytokine leptin can directly induce pro-inflammatory T helper 1 immune responses and the pathogenesis of chronic inflammation. We explored the association between plasma leptin and VA dysfunction in patients on maintenance hemodialysis (HEMO).

METHODS

A total of 344 consecutive patients who received anastomosis for VA at a single HEMO center between June 1, 2010 and December 31, 2021 were screened. Of these patients, 267 met the inclusion criteria and were included. ELISA was used to measure circulating levels of leptin.

RESULTS

The VA dysfunction group had a higher leptin level than the patent VA group. A higher concentration of leptin was independently and significantly associated with an elevated risk of VA dysfunction. Multiple logistic regression analysis showed that leptin, female sex, and hypertension were independently associated with VA dysfunction, even after adjusting for known biomarkers. We then evaluated the ability of leptin, female sex, and hypertension to predict the risk of VA dysfunction, and the area under the curve (AUC) for leptin was 0.626 (p = 0.0001). When leptin, female sex, and hypertension were added to this multivariate model, the AUC increased to 0.679 (p = 0.001) for leptin and hypertension, and 0.690 for leptin, hypertension, and female sex (p = 0.004). In addition, plasma leptin levels were associated with sex, body mass index, and hemoglobin.

CONCLUSIONS

In addition to the association between leptin and VA dysfunction, hypertension and female sex independently predicted VA dysfunction in patients with HEMO.

Dialysis capacity and nutrition care across Bangladesh: A situational assessment

Hemodialysis (HD) is a treatment for ensuring the survival of end-stage kidney disease (ESKD) patients, and nutrition care is integral to their management. We sent questionnaires to evaluate the total dialysis service capacity and nutrition services across all dialysis facilities (DF) in Bangladesh, with responses from 149 out of 166 active DFs. Survey results revealed that 49.7% of DFs operated two shifts, and 42.3% operated three shifts daily, with 74.5% holding between one and ten dialysis machines. Sixty-three percent of DFs served between one and 25 patients per week, and 77% of patients received twice-weekly dialysis. The average cost for first-time dialysis was 2800 BDT per session (range: 2500-3000 BDT), but it was lower if reused dialyzers were used (2100 BDT, range: 1700-2800 BDT). Nutritionists were available in only 21% of the DFs. Parameters related to nutritional health screening (serum albumin, BMI, MIS-malnutrition inflammation assessment, and dietary intakes) were carried out in 37.6%, 23.5%, 2%, and 2% of the DFs, respectively, only if recommended by physicians. Nutrition education, if recommended, was provided in 68.5% of DFs, but only in 17.6% of them were these delivered by nutritionists. The recommendation for using renal-specific oral nutrition supplements (ONS) is not a familiar practice in Bangladeshi DFs and, therefore, was scarcely recommended. Dialysis capacity across Bangladesh is inadequate to meet current or projected needs and nutrition education and support across the DFs to benefit improving patients' quality of life is also inadequate.

Extracorporeal Techniques in Kidney Failure

During the last decades, various strategies have been optimized to enhance clearance of a variable spectrum of retained molecules to ensure hemodynamic tolerance to fluid removal and improve long-term survival in patients affected by kidney failure. Treatment effects are the result of the interaction of individual patient characteristics with device characteristics and treatment prescription. Historically, the nephrology community aimed to provide adequate treatment, along with the best possible quality of life and outcomes. In this article, we analyzed blood purification techniques that have been developed with their different characteristics.

Unveiling the Clinical Benefits of High-Volume Hemodiafiltration: Optimizing the Removal of Medium-Weight Uremic Toxins and Beyond

Dialysis treatment has improved the survival of patients with kidney failure. However, the hospitalization and mortality rates remain alarmingly high, primarily due to incomplete uremic toxin elimination. High-volume hemodiafiltration (HDF) has emerged as a promising approach that significantly improves patient outcomes by effectively eliminating medium and large uremic toxins, which explains its increasing adoption, particularly in Europe and Japan. Interest in this therapy has grown following the findings of the recently published CONVINCE study, as well as the need to understand the mechanisms behind the benefits. This comprehensive review aims to enhance the scientific understanding by explaining the underlying physiological mechanisms that contribute to the positive effects of HDF in terms of short-term benefits, like hemodynamic tolerance and cardiovascular disease. Additionally, it explores the rationale behind the medium-term clinical benefits, including phosphorus removal, the modulation of inflammation and oxidative stress, anemia management, immune response modulation, nutritional effects, the mitigation of bone disorders, neuropathy relief, and amyloidosis reduction. This review also analyzes the impact of HDF on patient-reported outcomes and mortality. Considering the importance of applying personalized uremic toxin removal strategies tailored to the unique needs of each patient, high-volume HDF appears to be the most effective treatment to date for patients with renal failure. This justifies the need to prioritize its application in clinical practice, initially focusing on the groups with the greatest potential benefits and subsequently extending its use to a larger number of patients.

Methemoglobinemia in Hemodialysis Patients due to Acute Chlorine Intoxication: A Case Series Calling Attention on an Old Problem

INTRODUCTION

Hemodialysis uses municipal water that must be strictly purified and sterilized to be used for that procedure. Large amounts of decontaminants are often used, such as chlorine, and if these compounds are not subsequently removed they can be transferred to the blood of patients causing complications including methemoglobinemia.

METHODS

In this case series study, dialysis patients in one unit were evaluated. We reviewed clinical characteristics and laboratory findings obtained on the day when the water supply was disinfected with chlorine, with the aim to quantify methemoglobin concentrations. Our objective was to characterize the clinical presentation and management of patients who presented with methemoglobinemia on a specific index day. We also reviewed reported cases in the literature regarding this underreported complication.

RESULTS

Eight patients who presented with chlorine intoxication were evaluated. The methemoglobin concentrations were between 1.3% and 7.9% (reference value 0-1%). We believe this to be caused by water containing 0.78 mg/L of total chlorine. Seven patients presented with cyanosis, 4 with dizziness, 6 with dark brown blood, 4 with dyspnea, and 4 with headache and hemolytic anemia. Subjects were treated with supplemental oxygen, methylene blue, intravenous vitamin C, blood transfusions, and increased doses of erythropoietin. No patient died, and all continued with their usual hemodialysis sessions.

CONCLUSION

Acute chlorine intoxication transferred by the water used during hemodialysis sessions can present with methemoglobinemia accompanied by cyanosis, oxygen desaturation, and hemolytic anemia. Chlorine levels should be carefully monitored in the water used for hemodialysis treatment.

The Effect of Hemodialysis on Spectral and Temporal Processing Abilities and Speech Perception in Noise among Individuals with Chronic Kidney Disease

INTRODUCTION

The effect of chronic kidney disease (CKD) on hearing is well documented in the literature. Several studies have investigated the effect of hemodialysis on the peripheral auditory system among individuals with CKD. However, studies investigating the effect of hemodialysis on speech perception and auditory processing abilities are limited. The present study investigated the effect of hemodialysis on few auditory processing abilities and speech perception in noise among adults with CKD.

METHODS

A total of 25 adults with CKD undergoing hemodialysis regularly participated in the study. Spectral ripple discrimination threshold (SRDT), gap detection threshold (GDT), amplitude-modulation detection threshold (AMDT), and speech recognition threshold in noise (SRTn) were measured before and after hemodialysis. Paired samples "t" test was carried out to investigate the effect of hemodialysis on thresholds.

RESULTS

Results showed a significant improvement for SRDT, GDT, AMDT, and SRTn after hemodialysis among individuals with CKD.

DISCUSSION

Hemodialysis showed a positive effect on speech perception in noise and auditory processing abilities among individuals with CKD.

The Potency of Serum Omentin-1 Quantification in Predicting Major Adverse Cardiac and Cerebrovascular Events Risk in Patients Receiving Hemodialysis

Omentin-1 regulates inflammation, lipid accumulation, endothelial dysfunction, and atherosclerosis; the latter factors contribute to the occurrence of major adverse cardiac and cerebrovascular events (MACCE). This study aimed to explore the predictive implication of serum omentin-1 for MACCE risk in patients receiving hemodialysis. A total of 319 patients receiving hemodialysis and 160 healthy controls were prospectively enrolled in this study. Omentin-1 from serum was detected by enzyme-linked immunosorbent assay. MACCE was recorded during follow-up (median 18.9 months; range 1.9-62.9 months) in patients receiving hemodialysis. Omentin-1 was reduced in patients receiving hemodialysis versus healthy controls (P < 0.001). In patients receiving hemodialysis, omentin-1 was negatively related to C-reactive protein, total cholesterol, and low-density lipoprotein cholesterol (all P < 0.05); whereas omentin-1 was not related to other clinical characteristics. Notably, the 1-year, 2-year, 3-year, 4-year, and 5-year accumulating MACCE rates in patients receiving hemodialysis were 7.9%, 18.3%, 25.9%, 36.1%, and 41.4%, respectively. Interestingly, high omentin-1 related to decreased accumulating MACCE rate (P = 0.003), which was further validated by multivariate Cox regression analysis (hazard ratio = 0.458, P = 0.006). Additionally, by direct comparison, omentin-1 was reduced in hemodialysis patients who experienced MACCE compared to those who did not (P < 0.001); meanwhile, the receiver operator characteristic curve displayed that omentin-1 had an acceptable ability to estimate MACCE risk with an area under the curve (95% confidence interval) of 0.703 (0.628-0.777). Serum omentin-1 reflects reduced inflammation and lipid accumulation, as well as predicts decreased MACCE risk in patients receiving hemodialysis.

Development and Validation of Prediction Models for All-Cause Mortality and Cardiovascular Mortality in Patients on Hemodialysis: A Retrospective Cohort Study in China

Purpose

This study aimed to develop two predictive nomograms for the assessment of long-term survival status in hemodialysis (HD) patients by examining the prognostic factors for all-cause mortality and cardiovascular (CVD) event mortality.

Patients and methods

A total of 551 HD patients with an average age of over 60 were included in this study. The patients' medical records were collected from our hospital and randomly allocated to two cohorts: the training cohort (n=385) and the validation cohort (n=166). We employed multivariate Cox assessments and fine-gray proportional hazards models to explore the predictive factors for both all-cause mortality and cardiovascular event mortality risk in HD patients. Two nomograms were established based on predictive factors to forecast patients' likelihood of survival for 3, 5, and 8 years. The performance of both models was evaluated using the area under the curve (AUC), calibration plots, and decision curve analysis.

Results

The nomogram for all-cause mortality prediction included seven factors: age ≥ 60, sex (male), history of diabetes and coronary artery disease, diastolic blood pressure, total triglycerides (TG), and total cholesterol (TC). The nomogram for cardiovascular event mortality prediction included three factors: history of diabetes and coronary artery disease, and total cholesterol (TC). Both models demonstrated good discrimination, with AUC values of 0.716, 0.722 and 0.725 for all-cause mortality at 3, 5, and 8 years, respectively, and 0.702, 0.695, and 0.677 for cardiovascular event mortality, respectively. The calibration plots indicated a good agreement between the predictions and the decision curve analysis demonstrated a favorable clinical utility of the nomograms.

Conclusion

Our nomograms were well-calibrated and exhibited significant estimation efficiency, providing a valuable predictive tool to forecast prognosis in HD patients.

Malnutrition- inflammation- atherosclerosis (MIA) syndrome associates with periodontitis in end-stage renal disease patients undergoing hemodialysis: a cross-sectional study

Malnutrition-inflammation-atherosclerosis (MIA) syndrome is a significant risk factor for mortality in patients undergoing hemodialysis. This study aimed to investigate the association between MIA syndrome and oral health status in hemodialysis patients. A cross-sectional study was conducted on 254 hemodialysis patients. Comprehensive medical and dental examinations were performed. Three components were included to define MIA syndrome: Geriatric Nutritional Risk Index, serum high-sensitivity C-reactive protein, and history of cardiovascular events as indicators of malnutrition, inflammation, and atherosclerosis, respectively. The association of MIA syndrome components with periodontitis and occlusal support was examined by multiple-ordered logistic regression analysis. Of 254 participants, 188 (74.0%) had at least one component of MIA syndrome. After adjusting for possible confounding factors, severe periodontitis was significantly associated with presence of more components of MIA syndrome (odds ratio [OR]: 2.64, 95% confidence interval [CI], 1.44-4.84, p = 0.002) and inflammation and malnutrition components (OR: 2.47 and 3.46, 95% CI 1.16-5.28 and 1.70-7.05, p = 0.020 and 0.001). On the other hand, occlusal support, evaluated by Eichner index, was not significantly associated with MIA syndrome or any of its components. In conclusion, periodontitis is associated with MIA syndrome, particularly with inflammation and malnutrition in hemodialysis patients, independent of occlusal support.

Branched-chain ketoacid co-ingestion with protein lowers amino acid oxidation during hemodialysis: A randomized controlled cross-over trial

BACKGROUND & AIMS

Hemodialysis removes amino acids from the circulation, thereby stimulating muscle proteolysis. Protein ingestion during hemodialysis can compensate for amino acid removal but may also increase uremic toxin production. Branched-chain ketoacid (BCKA) co-ingestion may provide an additional anabolic stimulus without adding to uremic toxin accumulation. In the present study we assessed the impact of BCKA co-ingestion with protein on forearm amino acid balance and amino acid oxidation during hemodialysis.

METHODS

Nine patients (age: 73 ± 10 y) on chronic hemodialysis participated in this crossover trial. During two 4-h hemodialysis sessions, patients ingested 18 g protein with (PRO + BCKA) or without (PRO) 9 g BCKAs in a randomized order. Test beverages were labeled with L-[ring-¹³C₆]-phenylalanine and provided throughout the last 3 h of hemodialysis as 18 equal sips consumed with 10-min intervals. Arterial and venous plasma as well as breath samples were collected frequently throughout hemodialysis.

RESULTS

Arterial plasma total amino acid (TAA) concentrations during PRO and PRO + BCKA treatments were significantly lower after 1 h of hemodialysis (2.6 ± 0.3 and 2.6 ± 0.3 mmol/L, respectively) when compared to pre-hemodialysis concentrations (4.2 ± 1.0 and 4.0 ± 0.5 mmol/L, respectively; time effect: P < 0.001). Arterial plasma TAA concentrations increased throughout test beverage ingestion (time effect: P = 0.027) without differences between treatments (time∗treatment: P = 0.62). Forearm arteriovenous TAA balance during test beverage ingestion did not differ between timepoints (time effect: P = 0.31) or treatments (time∗treatment: P = 0.34). Whole-body phenylalanine oxidation was 33 ± 16% lower during PRO + BCKA when compared to PRO treatments (P < 0.001).

CONCLUSIONS

BCKA co-ingestion with protein during hemodialysis does not improve forearm net protein balance but lowers amino acid oxidation.

Expanded hemodialysis: what's up, Doc?

In recent years there has been an increasing interest in expanded hemodialysis (HDx), an emerging renal replacement therapy based on the use of medium cut-off membranes (MCO). Thanks to the internal architecture of these types of membranes, with a higher pore size and smaller fiber inner diameter to favor internal filtration rate, they can increase the removal of larger middle molecules in conventional hemodialysis. Secondarily, several reports suggest that this therapy potentially improve the outcomes for end-stage renal disease patients. However, HDx has not been defined yet and the characteristics of MCO membranes are not well stablished. The aim of this narrative review is to define HDx and summarize the dialyzers that have been used so far to perform this therapy, collect the evidence available on its efficacy and clinical outcomes compared with other hemodialysis techniques and settle the bases for its optimal prescription.

Impact of the teach-back method on caregiver outcomes using the "Timing it Right" framework for hemodialysis patients

Background

The caregivers play vital roles in the health care of hemodialysis patients. Ineffective education strategy for the caregivers negatively affects the care ability of caregivers. This study aimed to evaluate the effectiveness of the teach-back method based on the "Timing it Right" framework on the caregivers' care ability, emotions and health-related quality of life for hemodialysis patients.

Methods

The study involved 78 caregivers of 78 hemodialysis patients. Participants in the control group received routine nursing care and traditional oral health education, while those in the intervention group received health education through the teach-back method based on the "Timing it Right" framework. All participants were followed for 6 months. The degree of anxiety and depression of caregivers was evaluated through the Self-rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS), respectively. The care ability of caregivers was assessed by the Family Caregiver Task Inventory (FCTI). The health-related quality of life of hemodialysis patients was evaluated using the 36-item Short Form Health Survey (SF-36).

Results

Compared to baseline (T0), the SAS, SDS and FCTI scores of the intervention group were significantly reduced at the time of discharge (T1), three (T2) and 6 months (T3) (all p < 0.001). Besides, at T1, T2, and T3, the FCTI scores of the intervention group were significantly lower than that in control group (all p < 0.001). The SAS and SDS scores were also significantly lower in the intervention group at T1, T2, and T3 compared to the control group (all p < 0.001). For SF-36 scores, all domains of the intervention group were significantly higher than those of the control group at T1, T2 and T3, including physical functioning (p < 0.001), role physical (p = 0.007), bodily pain (p < 0.001), general health (p = 0.002), vitality (p = 0.043), social functioning (p = 0.016), role emotional (p = 0.002), and mental health(p = 0.025).

Conclusion

The application of teach-back method based on the "Timing it Right" framework could obviously alleviate the anxiety and depression of caregivers for hemodialysis patients. Furthermore, it could significantly improve the care ability of caregivers and the quality of life of patients.

Structure and Function of a Provincial Renal Pharmacy Program: Applying the Chronic Care Model to Address Equitable Access to Medication and Pharmacy Services

Purpose

We described the rationale, structure, design, and components of a provincial pharmacy services network for patients with kidney disease as a model for enabling equitable access and universal care to pharmacy services and medications across a wide range of clinical conditions, and geographic expanse in British Columbia (BC).

Sources of Information

These include minutes from 53 Pharmacy Services and Formulary (PS&F) Committee meetings held from 1999 to November 2022, documentation available on the British Columbia Renal (BCR) website, direct observation and participation in committee meetings, as well as interviews with key individuals involved in different aspects of the program.

Methods

We reviewed documents and data describing the evolution, rationale, and functioning of the BCR provincial pharmacy services system and used a variety of sources as mentioned above. In addition, a qualitative thematic synthesis of reports of chronic care models (CCMs) was conducted to map the program components into the chronic disease management models.

Key Findings

The components of the provincial pharmacy program (PPP) include (1) a PS&F committee, with interdisciplinary and geographical representation; (2) a community of dispensing pharmacies with standardized protocols and information; (3) a dedicated medication and pharmacy services budget, and regular evaluation of budget, outcomes, and performance; (4) provincial contracts for specific medications; (5) communication and education; and (6) information management system. Program components are described in the context of chronic disease management models. The PPP includes dedicated formularies for people with kidney disease at different points in the disease trajectory, including those on and off dialysis. Equitable access to medications is supported across the province. All medications and counseling services are provided to all patients registered in the program, through a robust distributed model, including community- and hospital-based pharmacies. Provincial contracts managed centrally ensure best economic value, and centralized education and accountability structures ensure sustainability.

Limitations

Limitations of the current report include lack of formal evaluation of the program on patient outcomes, but this is relative as the intention of this article is to describe the program which has existed for over 20 years and is fully functional. Formal evaluation of a complex system would include by costs, cost avoidance, provider, and patients' satisfaction. We are developing a formal plan for this reason.

Implications

The PPP is embedded in the provincial infrastructure of BCR and enables the provision of essential medications and pharmacy services for patients with kidney disease throughout the spectrum. The leveraging of local and provincial resources, knowledge, and expertise to implement a comprehensive PPP, ensures transparency and accountability and may serve as a model for other jurisdictions.

Homelessness, organ donation, transplantation, and a call for equity in the United States

While social justice is a pillar that society seeks to uphold, in the area of organ transplantation, social justice, equity, and inclusion fail in the unbefriended and undomiciled population. Due to lack of social support of the homeless population, such status often renders these individuals ineligible to be organ recipients. Though it can be argued that organ donation by an unbefriended, undomciled patient benefits the greater good, there is clear inequity in the fact that homeless individuals are denied transplants due to inadequate social support. To illustrate such social breakdown, we describe two unbefriended, undomiciled patients brought to our hospitals by emergency services with diagnoses of intracerebral haemorrhage that progressed to brain death. This proposal represents a call to action to remediate the broken system: how the inherent inequity in organ donation by unbefriended, undomiciled patients would be ethically optimized if social support systems were implemented to allow for their candidacy for organ transplantation.

Deep learning-based electrocardiographic screening for chronic kidney disease

BACKGROUND

Undiagnosed chronic kidney disease (CKD) is a common and usually asymptomatic disorder that causes a high burden of morbidity and early mortality worldwide. We developed a deep learning model for CKD screening from routinely acquired ECGs.

METHODS

We collected data from a primary cohort with 111,370 patients which had 247,655 ECGs between 2005 and 2019. Using this data, we developed, trained, validated, and tested a deep learning model to predict whether an ECG was taken within one year of the patient receiving a CKD diagnosis. The model was additionally validated using an external cohort from another healthcare system which had 312,145 patients with 896,620 ECGs between 2005 and 2018.

RESULTS

Using 12-lead ECG waveforms, our deep learning algorithm achieves discrimination for CKD of any stage with an AUC of 0.767 (95% CI 0.760-0.773) in a held-out test set and an AUC of 0.709 (0.708-0.710) in the external cohort. Our 12-lead ECG-based model performance is consistent across the severity of CKD, with an AUC of 0.753 (0.735-0.770) for mild CKD, AUC of 0.759 (0.750-0.767) for moderate-severe CKD, and an AUC of 0.783 (0.773-0.793) for ESRD. In patients under 60 years old, our model achieves high performance in detecting any stage CKD with both 12-lead (AUC 0.843 [0.836-0.852]) and 1-lead ECG waveform (0.824 [0.815-0.832]).

CONCLUSIONS

Our deep learning algorithm is able to detect CKD using ECG waveforms, with stronger performance in younger patients and more severe CKD stages. This ECG algorithm has the potential to augment screening for CKD.

Is preclinical diabetic retinopathy in diabetic nephropathy individuals more severe?

Purpose

To analyse the retinal vessel density and thickness characteristics of diabetic nephropathy (DN) individuals with preclinical diabetic retinopathy (DR) using optical coherence tomography angiography (OCTA).

Methods

This retrospective case-control study included 88 eyes of 88 type 2 DM patients with preclinical DR [44 non-DN (NDN) and 44 DN]. OCTA images and data were acquired using AngioVue 2.0 of the spectral domain OCT device. The foveal avascular zone (FAZ) area, superficial capillary plexus (SCP) and deep capillary plexus vessel densities, ganglion cell complex (GCC) and full retinal thicknesses, peripapillary capillary density and nerve fibre layer (RNFL) thickness were compared between the NDN and DN groups. The relationship between each renal function parameter and each OCTA parameter was analysed.

Results

SCP vessel density, GCC thickness and full retinal thickness were significantly reduced in DN individuals compared to NDN individuals [(NDN versus DN) SCP vessel density: 46.65 ± 3.84% versus 44.35 ± 5.25%, p=0.030; GCC thickness: 100.79 ± 5.92 μm versus 93.28 ± 8.66 μm, p<0.001; full retinal thickness: whole area: 287.04 ± 13.62 μm versus 277.71 ± 15.10 μm, p=0.005). Within the peripapillary area, capillary density was also significantly reduced in the whole area (50.19 ± 3.10% versus 47.46 ± 5.93%, p=0.016) and some sectors in the DN group, though RNFL thickness was only decreased in some sectors. For all individuals, estimated glomerular filtration rate (eGFR) correlated significantly with most OCTA parameters and then showed a significantly negative correlation with FAZ area (β=-16.43, p=0.039) in multivariate linear regression analysis. In the NDN group, eGFR showed a significantly negative correlation with FAZ area (β=-18.746, p=0.048) and a significantly positive correlation with SCP vessel density (β=0.580, p=0.036).

Conclusion

Preclinical DR may be more severe in DN individuals than in NDN individuals with regard to microvascular and microstructural impairment. Moreover, eGFR may be a good indicator for retinal microvascular impairment.

A system for preventing internal fistula needle dislodgement: Delphi study and pilot evaluation

AIM

To establish a scoring system for risk assessment (SSRA) for internal fistula needle dislodgement (IND) in hemodialysis (HD) patients.

METHODS

The SSRA was constructed based on literature search, medical history review, expert consultations, expert meeting (Delphi study), and analytic hierarchy process. Then, a pilot test was conducted at our hospital between August 1, 2020, and July 30, 2021. Consecutive patients requiring HD were included and randomly assigned to experimental and control groups (1:1 ratio). Control group was treated with the routine procedures, while the experimental group was treated with strengthened nursing measures based on the individual risk assessed by SSRA. Finally, the incidence of IND was compared between the two groups.

RESULTS

For the Delphi study, 16 experts in dialysis nursing in Zhejiang, Shanghai, Guangzhou, and Qinghai were included. The final draft of the SSRA included three first-level indices, 11 second-level indices, and 26 third-level indices. A total of 218 HD patients were included. The IND rate in the experimental group was significantly lower than that in the control group (p < .01).

CONCLUSION

We established a scientific, reliable, and feasible SSRA for timely identification of HD patients with high risk of IND and the corresponding nursing procedures to prevent IND.

Anthocyanins-rich interventions on oxidative stress, inflammation and lipid profile in patients undergoing hemodialysis: meta-analysis and meta-regression

The aim of this systematic review and meta-analysis was to evaluate the effects of anthocyanins-interventions on oxidative stress, inflammation, and lipid profile in patients undergoing hemodialysis. This systematic review and meta-analysis were registered on the International Prospective Register of Systematic Reviews (PROSPERO CRD42020209742). The primary outcome was anthocyanins-rich intervention on OS parameters and secondary outcome was anthocyanins-rich intervention on inflammation and dyslipidemia. RevMan 5.4 software was used to analyze the effect size of anthocyanins-rich intervention on OS, inflammation and dyslipidemia. Meta-analysis effect size calculations incorporated random-effects model for both outcomes 1 and 2. Eight studies were included in the systematic review (trials enrolling 715 patients; 165 men and 195 women; age range between 30 and 79 years). Anthocyanin intervention in patients undergoing hemodialysis decrease the oxidant parameters (std. mean: -2.64, 95% CI: [-3.77, -1.50], P ≤ 0.0001, I² = 97%). Specially by reduction of malondialdehyde products in favor of anthocyanins-rich intervention (std. mean: -14.58 µmol.L, 95% CI: [-26.20, -2.96], P ≤ 0.0001, I² = 99%) and myeloperoxidase (std. mean: -1.28 ηg.mL, 95% CI: [-2.11, -0.45], P = 0.003, I² = 77%) against placebo group. Decrease inflammatory parameters (std. mean: -0.57, 95% CI: [-0.98, -0.16], P = 0.007, I² = 79%), increase HDL cholesterol levels (std. mean: 0.58 mg.dL, 95% CI: [0.23, 0.94], P = 0.001, I² = 12%) against placebo group. Anthocyanins-rich intervention seems to reduce oxidative stress, inflammatory parameters and improve lipid profile by increasing HDL cholesterol levels in patients with chronic kidney disease undergoing hemodialysis.

Molecular epidemiology and associated risk factors of oral cavity parasites in hemodialysis patients in western Iran

Renal disorders are able to make patients more susceptible to infections, including those caused oral cavity infections. Today, it has been proven that during end stage renal failure, hemodialysis results in acquired immune response defects through failings of humoral and cell-mediated immune. This survey was intended to assess the molecular epidemiology and associated risk factors of Entamoeba gingivalis and Trichomonas tenax as the main oral cavity protozoa in hemodialysis patients in Lorestan Province, western Iran. The investigation was performed on 73 hemodialysis patients referring to hemodialysis centers of Lorestan Province, Iran during May 2021 to February 2022. The frequency of oral cavity protozoa was investigated using microscopic and conventional polymerase chain reaction (PCR). A provided questionnaire with a number of demographical information and related risk factors was completed for each patient. The results showed that E. gingivalis and T. tenax parasites were found in 18 (24.6%) and 20 (27.4%) of the hemodialysis participants by microscopic and PCR test, respectively. Among samples, 13 (17.8%) of the hemodialysis participants were infected with E. gingivalis; whereas 7 (9.6%) of the participants were positive for T. tenax. No significant association was reported between gender, age, education, flossing, use of mouthwash, and prevalence of oral protozoa in hemodialysis participants. However, a significant correlation was observed among between living in rural regions (OR = 13.16; 95% CI = 2.64-56.81; p = 0.002), brushing teeth (OR = 8.51; 95% CI = 1.71-42.3; p = 0.009) and prevalence of oral protozoa in hemodialysis participants. The findings of these epidemiological study clearly showed the high frequency of oral cavity parasites in hemodialysis patients in Lorestan Province, Western Iran. Awareness of the main risk factors for oral cavity parasites particularly teeth brushing is necessary in refining public and oral health policies in hemodialysis patients. Consequently, dental practitioners, nephrologist, and urologist must be alert of these risk factors to carefully identify and achieve oral health concerns in hemodialysis patients to prevent the oral diseases and infections.

Intradialytic Protein Ingestion and Exercise do Not Compromise Uremic Toxin Removal Throughout Hemodialysis

OBJECTIVE

Dietary protein and physical activity interventions are increasingly implemented during hemodialysis to support muscle maintenance in patients with end-stage renal disease (ESRD). Although muscle maintenance is important, adequate removal of uremic toxins throughout hemodialysis is the primary concern for patients. It remains to be established whether intradialytic protein ingestion and/or exercise modulate uremic toxin removal during hemodialysis.

METHODS

We recruited 10 patients with ESRD (age: 65 ± 16 y, BMI: 24.2 ± 4.8 kg/m²) on chronic hemodialysis treatment to participate in this randomized cross-over trial. During hemodialysis, patients were assigned to ingest 40 g protein or a nonprotein placebo both at rest (protein [PRO] and placebo [PLA], respectively) and following 30 min of exercise (PRO + exercise [EX] and PLA + EX, respectively). Blood and spent dialysate samples were collected throughout hemodialysis to assess reduction ratios and removal of urea, creatinine, phosphate, cystatin C, and indoxyl sulfate.

RESULTS

The reduction ratios of urea and indoxyl sulfate were higher during PLA (76 ± 6% and 46 ± 9%, respectively) and PLA + EX interventions (77 ± 5% and 45 ± 10%, respectively) when compared to PRO (72 ± 4% and 40 ± 8%, respectively) and PRO + EX interventions (73 ± 4% and 43 ± 7%, respectively; protein effect: P = .001 and P = .023, respectively; exercise effect: P = .25 and P = .52, respectively). Nonetheless, protein ingestion resulted in greater urea removal (P = .046) during hemodialysis. Reduction ratios and removal of creatinine, phosphate, and cystatin C during hemodialysis did not differ following intradialytic protein ingestion or exercise (protein effect: P > .05; exercise effect: P>.05). Urea, creatinine, and phosphate removal were greater throughout the period with intradialytic exercise during PLA + EX and PRO + EX interventions when compared to the same period during PLA and PRO interventions (exercise effect: P = .034, P = .039, and P = .022, respectively).

CONCLUSION

The removal of uremic toxins is not compromised by protein feeding and/or exercise implementation during hemodialysis in patients with ESRD.

Does temporary transfer to preoperative hemodialysis influence postoperative outcomes in patients on peritoneal dialysis? A retrospective cohort study

Background

The associations between preoperative transfer to hemodialysis (HD) and postoperative outcomes in patients on chronic peritoneal dialysis (PD) remain unknown. We conducted this retrospective cohort study to investigate whether preoperative HD could influence surgical outcomes in PD patients undergoing major surgeries.

Methods

All chronic PD patients who underwent major surgeries from January 1, 2007, to December 31, 2020, at Peking University First Hospital were screened. Major surgery was defined as surgical procedures under general, lumbar or epidural anesthesia, with more than an overnight hospital stay. Patients under the age of 18, with a dialysis duration of less than 3 months, and those who underwent renal implantation surgeries and procedures exclusively aimed at placing or removing PD catheters were excluded. Patients involved were divided into either HD or PD group based on their preoperative dialysis status for further analysis.

Results

Of 105 PD patients enrolled, 65 continued PD, and 40 switched to HD preoperatively. Patients with preoperative HD were significantly more likely to develop postoperative hyperkalemia. The total complication rates were numerically higher in patients undergoing preoperative HD. After adjustment, the incidence of postoperative hyperkalemia or any other postoperative complication rates were similar between groups. There were no differences in long-term survival between the two groups.

Conclusions

It does not seem indispensable for PD patients to switch to temporary HD before major surgeries.